OFFICE OF THE BURSAR 


Credit Card Authorization Form 

PLEASE FILL OUT ALL INFORMATION REQUESTED AND FAX TO 516.686.7833 

Student name ______________________________________________________ 
Social Security number _______________________________________________ 
Students address ____________________________________________________ 
City __________________________ State ______ ZIP _____________________ 
Student phone number (day) ________________ (evening) __________________ 
Apply payment to ________________ for ________________________________ 

(semester) (Indicate: tuition, fees, flex, deposit, etc.) 
Cardholder name (if different from student) ______________________________ 
Cardholder address (if different from student) _____________________________ 
City __________________________ State ______ ZIP _____________________ 
Cardholder phone number ____________________________________________ 

Credit card (please check one): 
___ Visa ____ MasterCard ____ American Express ____ Discover 
Card number _______________________________________________________ 
Expiration Date (mm/yy) ____________ Card security code (CSC) ** __________ 
Amount _______________ 


By signing below, I understand that I am using my credit card to pay tuition at New 
York Institute of Technology (NYIT), and I authorize funds from my credit card to be 
used for this purpose. 


Signature of cardholder _______________________________________________ 


**What is the card security code (CSC)? 
Discover, VISA, and MasterCard: 

Look at the signature box on the back side of your card. You should see your 16-digit credit card 
number followed by a three-digit code. This three-digit code is your card security code (CSC). 

American Express: 

Look for the four-digit code printed on the front of your card just above and to the right of your 

main credit card number. This is your card security code (CSC). 

A1010/0607/5M 


